What are the recommended injection options and their risks for treating a patient with Achilles tendon tendinopathy?

Achilles Tendon Injections: Avoid Corticosteroid Injections Into or Around the Tendon

Corticosteroid injections into or around the Achilles tendon should be avoided due to the risk of tendon rupture and lack of long-term benefit. 1, 2

Why Corticosteroid Injections Are Not Recommended

The evidence strongly cautions against injecting corticosteroids into the Achilles tendon substance or peritendinous area:

• Injecting corticosteroids directly into the tendon substance causes deleterious effects on the tendon tissue itself. 1

• Peritendinous corticosteroid injections may inhibit healing and reduce the tensile strength of the tissue, predisposing to spontaneous rupture. 1, 2

• While corticosteroids may provide short-term pain relief in the acute phase, they do not alter long-term outcomes. 1, 3

• The role of inflammation in Achilles tendinopathy is unclear, as most cases represent chronic degenerative tendinosis rather than inflammatory tendonitis, making anti-inflammatory treatments theoretically less effective. 1, 4

Recommended Non-Injection Treatment Options

Instead of injections, the evidence supports these treatment modalities:

First-Line Treatments

• Eccentric strengthening exercises are the gold standard and most effective conservative treatment, with 60-90% improvement in pain and function in randomized trials. 2, 3

• Activity modification by reducing pain-provoking activities while maintaining sufficient activity to prevent muscle atrophy. 1, 2

• Cryotherapy (ice through a wet towel for 10-minute periods) provides effective short-term pain relief. 1, 2

• NSAIDs (preferably topical formulations to avoid gastrointestinal side effects) for short-term pain relief only. 1, 2

Second-Line Options for Refractory Cases

• Extracorporeal shock wave therapy has the highest evidence-based effectiveness alongside eccentric exercise. 5, 4

• Nitric oxide patches show promising results in current data. 4, 3

• Sclerotherapy targeting neovascularization has supportive evidence. 4

Alternative Injection Options (If Injection Is Absolutely Necessary)

If you are considering injection therapy despite the warnings:

• Platelet-rich plasma (PRP) injections have shown short-term efficacy for tendinopathy sufferers, though long-term data are lacking. 6

• Hyaluronic acid injections have been researched but lack strong evidence for effectiveness. 5

• These alternative injections should still be used with extreme caution and only after failure of conservative management for 6-8 weeks. 2

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into the Achilles tendon substance—this is the highest risk scenario for rupture. 1

• Do not use corticosteroid injections as a first-line treatment; they provide only temporary relief without addressing the underlying degenerative pathology. 4, 3

• Avoid prolonged immobilization, which causes muscle atrophy and deconditioning. 1

• Do not abandon conservative treatment prematurely—continue for at least 6-8 weeks before considering more aggressive interventions. 2

Treatment Algorithm

1. Initiate eccentric strengthening exercises, activity modification, cryotherapy, and topical NSAIDs for 6-8 weeks. 2, 3

2. If no improvement after 6-8 weeks, consider second-line modalities like shock wave therapy or nitric oxide patches. 2, 4

3. Reserve surgical debridement for patients who fail 3-6 months of conservative therapy. 3, 7

4. If injection therapy is absolutely necessary despite the evidence, consider PRP over corticosteroids, but only after conservative treatment failure. 6